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Baeza, Juan I; Boaz, Annette; Fraser, Alec; European Implementation Score Collaborative Group;(2016) The roles of specialisation and evidence-based practice in inter-professional jurisdictions: Aqualitative study of stroke services in England, Sweden and Poland. Social science & medicine (1982),155. pp. 15-23. ISSN 0277-9536 DOI: https://doi.org/10.1016/j.socscimed.2016.03.001
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Accepted Manuscript
The roles of specialisation and evidence-based practice in inter-professionaljurisdictions: A qualitative study of stroke services in England, Sweden and Poland
Juan I. Baeza, Annette Boaz, Alec Fraser
PII: S0277-9536(16)30101-0
DOI: 10.1016/j.socscimed.2016.03.001
Reference: SSM 10547
To appear in: Social Science & Medicine
Received Date: 16 March 2015
Revised Date: 26 November 2015
Accepted Date: 1 March 2016
Please cite this article as: Baeza, J.I., Boaz, A., Fraser, A., On behalf of the European ImplementationScore (EIS) Collaborative Group, The roles of specialisation and evidence-based practice in inter-professional jurisdictions: A qualitative study of stroke services in England, Sweden and Poland, SocialScience & Medicine (2016), doi: 10.1016/j.socscimed.2016.03.001.
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The roles of specialisation and evidence-based prac tice in inter-
professional jurisdictions: a qualitative study of stroke services in
England, Sweden and Poland.
Juan I Baeza 1 (Corresponding author) King’s College London Annette Boaz 2 St. George’s, University of London & Kingston Unive rsity Alec Fraser 3 London School of Hygiene and Tropical Medicine On behalf of the European Implementation Score (EIS) Collaborative Group
Acknowledgements The authors would like to acknowledge the time given to us by those who agreed to participate in this study, to the valuable comments from the three anonymous reviewers, to Prof. Ewan Ferlie for the very helpful comments that
1 Department of Management� King's College London� 150 Stamford Street� London SE19NH� UK [email protected] Tel: 020-78484634 2 Faculty of Health, Social Care and Education St George's, University of London 2nd Floor Grosvenor Wing St George's Hospital Cranmer Terrace London SW17 0RE UK [email protected] 3 LSHTM Department of Health Services Research and Policy 15-17 Tavistock Place London WC1H 9SH UK [email protected]
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he gave us to previous drafts of this article and to the European Commission (HEALTH-2007-3.1-1: Implementation of research into health care practice) who funded this study.
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The roles of specialisation and evidence-based practice in inter-professional
jurisdictions: a qualitative study of stroke services in England, Sweden and
Poland.
Abstract
This paper investigates how the concepts of clinical specialisation and evidence
influence the jurisdictional power of doctors, nurses and therapists involved in stroke
care in Sweden, England and Poland. How stroke care has become a distinct
specialism across Europe and the role that evidence has played in this development
are critically analysed. Five qualitative case studies were undertaken across the
three countries, consisting of 119 semi-structured interviews with a range of
healthcare workers. The informants were purposively selected and their perspectives
of evidence-based practice (EBP) within stroke care were explored. The data were
analysed through thematic content analysis. The two key themes that emerged from
the data were the health professionals’ degrees of EBP and specialisation. The
results illustrate how the two concepts of clinical specialisation and evidence are
interrelated and work together to influence the different professions’ degree of
professional jurisdiction. It is concluded that doctors’ professional dominance gives
them full jurisdiction in stroke care and that nurses’ and therapists’ degrees of
jurisdiction is dependent on their ability to specialise.
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Research highlights
• New medical evidence gives rise to the development of new jurisdictions in
healthcare.
• A professional’s degree of specialisation makes an important contribution to
their degree of jurisdiction.
• Specialisation allows non-doctors to gain partial jurisdiction of stroke care.
• National health care contexts influence professionals’ ability to specialise.
Key words: England; Poland; Sweden; jurisdictions; evidence; specialisation; stroke
care; Abbott.
Introduction
There is a paucity of studies of the inter-professional perspectives of evidence-based
practice (EBP) (Mykhalovskiy and Weir, 2004), the lived experiences of different
clinical professionals working in specific clinical specialities of EBP (Broom et al.
2009) and no comparative European studies that can shed light on the impact of
different national health system contexts. This research examined different
healthcare professionals’ perspectives of EBP and how this influenced their
professional jurisdiction. We use Abbott’s notion of professional jurisdiction as the
theoretical lens to analyse the inter-professional relations in stroke care in England,
Sweden, and Poland via five comparative case studies. Stroke care is an ideal
condition to investigate these inter-professional perspectives, as contemporary
stroke care is multidisciplinary; care is delivered by a team of doctors, nurses and a
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range of therapists. We argue that the twin concepts of EBP and specialisation
contribute to the degree of jurisdiction that these three different professional groups
have in stroke care in England, Sweden and Poland. Before presenting our case
study findings we examine the concepts of professionalisation and jurisdiction,
evidence in healthcare in general and the development of EBP in particular, followed
by a discussion of the development of stroke care as a discrete clinical specialism.
Professionalisation and jurisdiction
There is a vast literature on the power of the medical profession (Johnson, 1972;
Mechanic, 1991) and its dominance over other healthcare professionals (Friedson,
1970). The intention of this paper is not to present a précis of this important
literature, instead we investigate the contemporary inter-professional relations in a
particular health speciality in different contextual settings. Much of the literature on
healthcare professionals’ have been uni-professional and ignore the important inter-
professional relations. Abbott’s (1988) concept of professional jurisdictions is
valuable in investigating how and why inter-professional jurisdictional disputes occur
within an interrelated system.
We empirically advance Abbott’s (1988) argument that “the development of the
formal attributes of a profession is bound up with the pursuit of jurisdictions and the
besting of rival professions” (p.30). Abbott’s concept of jurisdiction is useful to
examine inter-professional relations as; “It shows how professions both create their
work and are created by it” (p.316). Abbott argues that scholars of the professions
had not examined a key aspect of professional life: inter-professional competition
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(p.2). This competition leads to disputes over jurisdictional boundaries amongst
professional groups that determine the history of the professions. According to
Abbott the correct unit of analysis is the jurisdiction (p.112), which is defined as a
particular area of work that has a distinctive body of knowledge (Timmins and Nairn,
2015: 9). The elaboration of strong evidence has established a distinctive body of
knowledge for stroke care that has developed into a professional jurisdiction within
which professional groups will vie for control. Before examining the jurisdictional
dimensions of stroke care it is important to discuss how stroke care became a
distinct professional jurisdiction by considering the key concepts of EBP and
specialisation.
Evidence-based practice
Evidence-based medicine (EBM) changes medical practice from being primarily
grounded on tacit knowledge to one characterised by encoded knowledge (Dopson
et al. 2003; Greenhalgh et al. 2008). EBM is not a purely scientific endeavour, what
EBM is and how it is defined is contested and hence political (Harrison and
McDonald, 2008). Timmermans (2008:167) argues that EBM serves a number of
purposes:
EBM offers a dominant and sweeping social mechanism to control unruly
individual professionals, regain the public’s trust, and shore up the scientific
quality of the professional medical project that has spread from physicians to
other allied health professions.
This quote suggests that the influence of EBM extends beyond doctors and the term
evidence-based practice (EBP) is the inclusive term for the work that all healthcare
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professionals engage. EBP has become the accepted orthodoxy and is now
regarded as normative clinical practice (Lambert, 2006). A key EBP attribute is that
not all evidence is considered equivalent, but a hierarchy of evidence which is
dependent on the research design and its implied ‘validity’, which is itself a contested
term (Grossman et al. 2005). The randomised control trial (RCT) sits at the top of
this hierarchy; non-randomised controlled trials, case studies and observational
studies occupy lower ranks on the EBP ladder, while qualitative studies are
considered comparable to ideas and opinions (Harrison and McDonald, 2008). The
EBM pioneers defend this hierarchy by arguing that:
the randomised trial, and especially the systematic review of several
randomised trials, is so much more likely to inform us and so much less likely
to mislead us, it has become the ‘gold standard’ for judging whether a
treatment does more harm than good. (Sackett et al. 1996: 71)
This dominant view has been criticised by other healthcare professions, such as
nursing, which questions its appropriateness to the goals of nursing (Wall, 2009).
Critical discussions about how to incorporate qualitative research into systematic
reviews and clinical guideline construction to reflect a more comprehensive
understanding of the contribution of different types of research to the overall goals of
EBP challenges this dominant EBP narrative (Dixon-Woods & Fitzpatrick, 2001;
Dixon-Woods et al, 2006). Others have emphasised the importance of distinguishing
between effectiveness and efficacy (Gartlehner et al, 2006) in RCTs and the role for
patient engagement to improve EBP (Greenhalgh et al, 2014).
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Notwithstanding these challenges, for others (Borgerson, 2005), the RCT remains at
the pinnacle of the evidence hierarchy, creating a bias to healthcare provision that is
amenable to the RCT. This is pertinent for therapists in particular (such as
physiotherapists, occupational therapists and speech and language therapists). For
example, a study into evidence and the provision of physical therapies for young
children with motor disabilities reported that of 444 intervention study papers only 31
met the accepted (RCT type) criteria for evidence (Landsman, 2006). The lack of
good quality RCTs for therapists’ interventions is often cited in the literature
(Landsman, 2006; Leung, 2002). Critics argue that much EBP is inappropriate in
therapists’ clinical work and that a fundamental clash exists between the medical
research and therapy paradigms leading to the “therapies’ dilemma” resulting from
the medical model of evidence failing to recognise the value of non-RCT research
designs (Grimmer et al. 2004). However, clinical practice is not solely governed by
evidence, Greenhalgh et al (2008) argue that it results from the synthesis of
professional judgement (tacit knowledge) and formal rule based systems such as
EBP (encoded knowledge), concluding that encoded knowledge alone was not
sufficient for clinical action.
One might conclude that the development of EBP is an example of what Abbott
called an internal source of disturbance, a disruption that occurs from within the
professions themselves, that has largely strengthened the medical profession’s
jurisdictional claims (96-98). However, the impacts of EBP on the medical profession
are more complex (Armstrong, 2002). On the one hand the development of EBP
challenges the medical profession as it erodes the profession’s clinical autonomy by
increasing their accountability but on the other, by formulating EBP on a narrow and
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somewhat bio-medical model of scientific evidence it can perpetuate and preserve
the medical profession’s dominance among other healthcare professionals
(Timmermans, 2005).
In terms of inter-professional jurisdictions EBP can be used by the medical elites to
reinforce their power within a medical system, as they are often responsible for
constructing evidence based clinical guidelines that dictate the clinical work of
nurses, therapists and doctors. These developments create a paradox that
diminishes health professionals’ clinical autonomy while strengthening their
professional autonomy by maintaining control of the construction of clinical
guidelines and audit systems (Timmermans and Berg, 2003) and reinforces doctors’
professional dominance over other healthcare professionals (Light, 2000). For
example, Timmermans and Oh (2010) argue that the medical profession
successfully minimised the challenges to their jurisdiction posed by complementary
medical practitioners by incorporating and side-lining their activities, thereby bringing
them into their sphere of influence and control. Light (2000) argues that the situation
is dynamic; as medical power becomes dominant it is challenged by a range of
countervailing powers such as nurses and therapists in the case of stroke who
attempt to address the imbalance.
We now turn to how evidence has helped stroke care develop into a distinct
specialty.
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Developing stroke as a specialty
Globally, stroke has been a leading cause of death and disability for many years
(Johnston et al, 2009). Stroke predominantly affects the elderly and historically there
have been a lack of effective treatments (Pound et al, 1997). Issues of historical path
dependency are important for understanding socio-professional status developments
in comparative international analysis. Different medical professionals (neurologists,
geriatricians, internalists) historically claimed jurisdiction over stroke patients. In
Poland the role of neurologists in stroke development was stronger than in England
and Sweden resulting in a more medically dominated management of stroke. In
England and Sweden, lacking such neurological dominance, stroke care developed
along multi-disciplinary lines.
Establishing a distinctive body of knowledge and good evidence on effectiveness
enabled stroke medicine to become an important clinical specialism. Two recent
evidence-based interventions have been significant in stroke care (Langhorne and
Dennis, 1998). The first is the development of specialised Stroke Units (SUs), where
stroke patients receive specialised multidisciplinary care from doctors, nurses and
therapists in a specific location within the hospital (Stroke Unit Triallists
Collaboration, 2007). The second is Thrombolysis – a drug that offers a radical
improvement in outcomes for certain stroke types (NINDS, 1995). By the mid-1980s
SUs were proliferating throughout Sweden, while England and Poland followed
similar patterns, however, implementation of SU care was slower.
By 2008 the transformation of stroke care was such that the Royal College of
Physicians (RCP) and NICE stated:
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Over the last two decades, a growing body of evidence has overturned the
traditional perception that stroke is simply a consequence of aging which
inevitably results in death or severe disability. [emphasis added]. (NICE, 2008)
It is worth noting the importance of the word evidence in the extract above, which
transforms the clinical perceptions relating to stroke. Both professionals and policy
makers were keen to present evidence as being central to this transformation.
The external forces of organisational (SUs) and technological (thrombolysis)
innovations opened up a new jurisdictional area that became available for
professional capture through inter-professional competition. According to Abbott
(1988), professions’ jurisdictional claims are made up of three parts: classifying a
problem (diagnosis); analysis of the problem (inference); and finally proposing a
treatment to tackle the problem (treatment) (p.40). Stroke clearly displays these
three: high morbidity and mortality from stroke (diagnosis); producing evidence that
stroke patients can be effectively treated (inference); and developing organisational
(SUs) and medical interventions (thrombolysis) to effectively treat stroke (treatment).
Doctors, with the backing of their strong professional organisation, gained overall
control of key aspects of stroke treatment (such as the administration of
thrombolysis) and theoretically ought to be able to colonise the new jurisdiction of
stroke care. However, our data illustrate that a more complex inter-professional
process of negotiation emerges between and within the various professional groups
of nursing and the therapies.
For example, whilst research shows that the roles of specialist nurses are contested
in different European countries (Dury et al, 2014), the recent introduction of specialist
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nurse roles (in stroke and other specialisms) may be seen as a political attempt to
counter rising costs and physician shortages by transferring roles and responsibilities
from doctors to nurses (Wanless, 2002) whilst simultaneously providing the nursing
profession with an opportunity to further its own jurisdictional claims (Kroezen et al,
2014). Nancarrow and Borthwick (2005) identify similar processes with respect to
therapists. These processes have been more pronounced in England and Sweden
than Poland for two reasons: physician salaries are higher in Sweden and England
than in Poland, making role transference more attractive. Secondly, nurses have
been better able to capitalise on opportunities to specialise in Sweden and England
than in Poland because of their higher educational levels on entry. The picture for
therapists is less researched but appears to be more fragmented within and across
the three countries.
Before exploring the study’s findings we will describe our research methods.
Methods
As part of a European Commission seventh framework funding programme, five
comparative case studies were conducted in England, Sweden and Poland to
examine the level of implementation of evidence into practice in stroke services. The
case studies focused on SUs but included community and general practice (GP)
services in England (2 hospital sites) Sweden (2 hospital sites) and Poland (1
hospital site). Qualitative case studies allowed the team to explore stroke services in-
depth and to ask the relevant ‘how’ and ‘why’ questions that emerged (Yin, 2003). A
comparative case study design was used to construct a large-scale database of 119
interviews. This multiple case study approach enabled us to develop credible case
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and cross case analysis to establish the internal consistency of the information
gathered and use this analysis to develop theoretical constructs from the data
(Eisenhardt, 1989; Eisenhardt and Graebner, 2007). The informants were asked
about their professional background and work history, if they used evidence research
in their work, (and if so) why and how, whether they were encouraged to do so (and
if so by whom) and their perspectives on the use of evidence in their area of work.
England, Sweden and Poland were selected following discussions with European
stroke specialists that formed part of the European Implementation Score
Collaborative Group. This collaborative consists of public health specialists, stroke
clinicians, social scientists and patient group representatives from across Europe
conducting research measuring the implementation of research into stroke care
practice (project reference to be inserted after review).
According to national audit data (Rudd et al. 2005), Sweden has one of the most
highly developed services, while stroke services in England are in a more
developmental stage and Poland has the least comprehensively developed stroke
services. Both Sweden and England treated 88% of stroke patients on SUs in 2010
(RCP, 2011; Riks-stroke, 2010) and in Poland there are significant geographical
differences in stroke care in terms of patient outcomes (Niewada, 2006).
The case study hospital sites in England and Sweden included two urban and two
rural hospitals to capture data from different contexts in terms of patient
demography; influence and existence of competing hospitals; difficulties in attracting
and retaining skilled staff; and differences in community care arrangements.
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Achieving access proved more problematic in Poland, partly because there are far
fewer comprehensive SUs in Poland (Członkowska et al. 2010), especially in rural
locations. However, we were keen to include data from an East European health
system with a very different history (both in terms of stroke and more generally). We
secured access to only one Polish case study site. This was augmented by
conducting three interviews with staff from other geographical sites in Poland. These
were with a rurally based GP, a middle grade neurologist from a different Polish city
and with the clinical lead doctor from a different hospital in the same city as our main
site, these interviews allowed us to develop a more balanced picture overall.
Furthermore, conscious of the particular nature of the main Polish case study site,
we asked our Polish informants to comment on experiences elsewhere and reflect
upon how representative the main case study site was compared to the more
generalised Polish experience.
Interviews
Informants were purposively sampled to represent the different managerial and
professional groups involved in delivering stroke care in the three countries. The
purposive sample included a range of both clinical and managerial staff from the
hospital based SU, emergency medicine, radiology, ambulance service, community
rehabilitation services, including physiotherapists, occupational therapists, speech &
language therapists, dieticians and psychologists, commissioners of services and
GPs. A total of 119 interviews were carried out as shown in table 1 below.
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Table 1: Roles and genders of informants
* M=Male; F=Female
The interviews were arranged and conducted by AF between October 2010 and
September 2011. The interviews ranged from 25 mins-90 minutes (most lasting an
hour) and were semi-structured following the outline of the interview schedule. All
informants were asked for an example of EBP and implementation in stroke care.
The interviewer let them describe the implementation in their own words before
following up with supplementary questions. Informants were then asked for an
example of EBP in stroke care, which was yet to be locally implemented. Most
informants opted to talk about the implementation of SU care or emergency
thrombolysis and their associated organisational challenges. Some junior nurses
discussed small-scale local interventions linked to patient care (e.g. oral hygiene)
often allied to research projects being undertaken by nursing colleagues. Therapists
Professional group
English case study 1
English case study 2
Swedish case study 1
Swedish case study 2
Polish case study
Commissioner 3 M*=2; F*=1
0 1 F=1
1 F=1
0
Manager 4 M=3; F=1
3 M=1; F=2
3 M=1; F=2
3 M=2; F=1
4 M=1; F=3
Doctor 3 M=3
3 M=3
5 M=1; F=4
3 M=3
10 M=5; F=5
Nurse 7 M=2; F=5
4 M=1; F=3
8 M=2; F=6
6 M=2; F=4
3 F=3
Healthcare Assistant
1 F=1
1 F=1
1 F=1
0 0
Therapist 5 M=2; F=3
7 M=2; F=5
6 M=1; F=5
5 M=1; F=4
5 M=3; F=2
GP 1 M=1
1 M=1
3 F=3
2 M=1; F=1
1 M=1
Ambulance service
1 M=1
1 M=1
1 F=1
1 M=1
1 M=1
Welfare board 0 0 0 1 M=1
0
Total (119) M=50; F=69
25 M=14; F=11
20 M=9; F=11
28 M=5; F=23
22 M=11; F=11
24 M=11; F=13
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frequently discussed various interventions and then spontaneously reflected on the
difficulties in describing much of these as ‘evidence based’ or not.
The interviews took place at the informants’ workplaces normally in private locations.
Although interpreters were offered to the Swedish informants none were needed, in
Poland interpreters were used to conduct the interviews with some junior therapists,
all the nurses and ambulance/social workers.
Interviews were recorded, transcribed and then entered into Nvivo for coding (QSR
International, 2008). The initial codes were generated from a close reading of the
transcripts and were based on the interview schedule, which primarily focused on
informants’ perspectives of implementing stroke research evidence into practice.
However, the data analysis had an inductive component and various other issues
emerged such as the implications of stroke becoming a distinct clinical specialisation
and informants’ views of EBP, which are the focus of our findings. The authors
independently read various transcripts from all five case studies and discussed the
coding frame throughout the data analysis to insure reliability (Miles and Huberman,
1984; Glaser and Strauss, 1967). Box 1 below provides brief profiles of the five case
study sites.
Box 1: Case study profiles
English case study 1 (ECS1)
This is a district general hospital that is geographically isolated, impacting upon staff
recruitment. It serves a population of 200,000 and has a staff of 3,000. It is affiliated
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with the local medical school but is less prestigious than other specialist hospitals in
the region, however, other hospitals are too distant to compete for SU patients. The
hospital’s historical stroke care performance is low. Patients are discharged with a
care plan to be implemented by community therapists and once completed the
patient is discharged to their GP.
English case study 2 (ECS2)
This teaching hospital is in a large southern city, serving a population of 500,000 with
a staff of 4,000. The hospital’s SU has been upgraded to a large combined hyper
acute stroke unit and SU over the past two years. Most patients leave the SU with a
discharge plan and a community therapy team will visit patients once every week for
six weeks and then discharged to their GP.
Swedish case study 1 (SCS1)
The hospital is centrally located in a large Swedish city and a similar size to ECS2. It
is affiliated with the university, but is less prestigious than another of the city’s
hospitals. There are elements of collaboration and competition amongst the local
hospitals. This hospital has an especially high number of stroke patients who have a
very short stay on the SU. Lack of bed capacity is a recognised problem at this
hospital. The SU staff stated that post-stroke rehabilitation care provision had
become less generous and more fragmented.
Swedish case study 2 (SCS2)
This is a district general hospital in a rural area in Western Sweden, serving a
population of 150,000 and has a 20 bed SU. There are 3 other hospitals affiliated
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with this site, each with an SU serving their small local town populations. There are
staff recruitment and retention problems. Patients stay on the SU longer and get
more therapy input prior to discharge than SCS1. A special factor in SCS2 was the
existence of GPs with special rehabilitation/stroke interests who coordinated care as
part of a pilot scheme.
Polish case study (PCS)
The interviews here (apart from three mentioned earlier) centred on a hospital in a
large city that is considered a centre of national excellence for neurological
conditions including stroke, making this case a positive outlier for Poland as a whole.
The hospital serves a population of 200,000. The data indicated that stroke care was
gradually improving in Poland following the implementation of SUs and the
development of thrombolysis; however, the starting base of stroke care in Poland is
lower than in Sweden and England. The provision of post SU care in Poland was
highlighted as being particularly deficient.
Results
Firstly, it is important to note the differences in funding and organisational structure
of the three countries’ health systems. Swedish healthcare is largely administered
and financed locally; England is funded by national taxation and has a centralised
organisational structure; Poland has a decentralised mandatory health insurance
system alongside supplementary government funding and out-of-pocket payments
(Sagan et al, 2011). All three countries faced similar challenges in changing the
perception of stroke as a disease and developing stroke care into a recognised
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medical specialty. At the macro level, stroke care developments have been localised
and clinician led in Sweden, whilst in England and Poland, a central government
target driven approach has been more important in transforming services.
A composite approach was developed to assess the degree of EBP of each
professional group at the five sites. The degree of EBP was based on both the
narratives from the research interviews about professionals’ attitudes and also, their
self-reported use of EBP. For example, doctors stated how EBP aligned with their
professional goals, therapists argued that they found EBP difficult with the evidence
available and it was largely absent in the Polish nurses’ narratives. In terms of EBP
use some professionals said they were doing it, others that they weren’t and/or
couldn’t and some were skeptical about EBP. These narratives were complemented
with historical audit/registry performance, national guidance from independent
experts, and local markers linked to SU implementation, thrombolysis availability and
recognised nursing and therapy standards. The degree of specialisation of each
professional group was also largely based on information gained from research
interviews such as informant backgrounds, job titles and reflexive identity. For
example, some doctors, nurses and therapists self-identified as ‘stroke specialists’
whilst others emphasised the ‘generalist’ nature of their work. This was closely linked
to whether staff exclusively treated stroke patients, or spent significant parts of their
time treating non-stroke patients. The degree of professional jurisdiction relates to
the relative power and influence different professional groups enjoyed around
strategic and operational matters delivering stroke care. The two key themes that
arose from our data in terms of examining inter-professional jurisdictions were the
different degrees of EBP and specialisation that the three professional groups
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displayed. Our results illustrate how these two topics are interrelated and worked
together to influence the different professions’ degree of professional jurisdiction
within stroke care.
Degrees of evidence-based practice
Evidence has had a major influence in developing stroke care into a separate clinical
specialty. The degree to which a profession can construct their practice as being
evidence based and thus develop an expertise can strengthen its jurisdictional
claims.
The literature reviewed illustrated that how evidence is constructed is important in
terms of EBP. Although there is ‘strong’ and accepted evidence for certain aspects of
stroke care this is not true for all the features of stroke care. The therapists in all
three countries stated that there was a general lack of RCT type evidence for much
of their work:
… our research area, speech and language, pathology and communication
problems, there is lack of strength [of evidence], because you, it’s very difficult to get
randomised, double blind controlled studies [...] So that’s a problem. (SLT, SCS1)
… there’s not much evidence about physiotherapy in stroke. I think that the evidence
that we have, we know is mostly concerned with very precise and with detailed
problems, which are not always connected directly to clinical practice. (Head of
Therapies, PCS)
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The fact that the gold standard for credible evidence is the RCT greatly limited
therapists’ ability to display a high degree of EBP in their work:
...as therapists it’s hard to do research that’s, how can you say, you know, a
randomised controlled trial is so hard in therapy and blinding is so difficult. (OT,
ECS2)
This lack of evidence particularly affected community-based non-specialist
therapists:
Yes I think a lot of it is that there isn’t that much evidence out there, that’s the
problem for community, but a lot of it is more in an acute bias. [...] But to be honest,
there’s not that much in the community. And I think that’s the problem, because a lot
of us work on our experience rather than the research that’s out there. (Community
physiotherapist, ECS1)
In contrast stroke specialist therapists were more able to validate their practice by
drawing on their specialised experience of stroke patients (tacit knowledge):
So I think a lot of work with stroke and speech is about that, because we’re looking
at the damage and, you know, a scan can say one thing, how the person actually
functions in front of you is something very different. (SLT, ECS1)
… if I do an intervention and I see that kind of it’s not an evidence based feedback,
but if I see that you as a patient are performing better, then it’s an instant feedback
for me that pushes me to try it on other patients. (SLT, SCS2)
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In stark contrast, the stroke doctors in our study felt very able to illustrate their high
degree of EBP:
I think it’s just the prestige for the hospital that we can, we can show the effects of
our treatments, that we have a lot of patients thrombolysed and we can write papers
about that. (Neurologist, PCS)
The ambiguity of EBP is vividly articulated by this GP:
I’m right now in the middle of deciding if I’m really a believer of evidence-based
medicine or not, being a primary care physician. And that’s based on the fact that
most of the evidence based medicine is kind of – it was born somehow in the
hospitals, with selected populations which we never meet. We meet the real
patients, you know. [...] I certainly feel that I’ve done a good job if I follow the
evidence-based guidelines… (GP2, SCS1)
The Polish data clearly illustrate that EBP is within the medical profession’s
jurisdiction and outside the nurses’ realm of influence:
Okay, we [nurses] usually have to follow the [doctors’] instructions. We can suggest
ideas or such as changes but usually we will follow. […] We are usually not taking
part in the meeting - someone comes to the ward and tells us about research or any
issues around that... (Nurse, PCS)
Nurses’ weak position in Poland is in stark contrast to Sweden where stroke nurse
specialists (SNS) are deeply involved, and often leading on developing local
evidence based guidelines, reviewing practice and suggesting service changes
based on research. The SNS informants described an equal and colligate
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relationship with doctors, which differs from Abbott’s (1988) competitive depiction of
inter-professional relations:
We have both meetings with our doctors, the nurses and the doctors and we go
through what we’ve been doing the past month or months, and look at figures,
compare it to other hospitals. We also look at how the other departments are doing
their part of the chain of reactions. (SNS, SCS2)
These data suggest that stroke doctors are the most able to display a high degree of
EBP due to the nature of evidence. The accepted orthodoxy of the RCT in EBP
constrains therapists’ ability to exhibit a similar degree of EBP. The weak position of
Polish nurses in terms of their involvement in EBP is clearly illustrated, as is the
relatively strong position of the Swedish SNS, which we discuss further in the next
section. In jurisdictional terms, it is the stroke doctors that have greatest authority in
stroke care by virtue of belonging to a powerful professional organisation (the
medical profession) and their high degree of EBP. However, our data also indicate
the importance of specialisation, which is illustrated in the following section.
Degrees of specialisation
The literature reviewed illustrated how stroke care has gained prominence due to its
ability to develop as a distinct specialist service, which has had a positive influence
on stroke care specialists:
But this specialisation in the stroke units, our staff grew, they were, they felt
internal confidence. We worked with something special, we are very good in this
job, this stroke job, and it raised up the nurses, the paramedics and so on, you
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know, we get some higher ranking on the social scale in the hospital. ‘I’m not an
ordinary nurse, I’m a stroke nurse.’ (Senior manager, SCS2)
In essence our data suggest that the professions that can claim to be stroke
specialists can gain greater authority than those who cannot. Nursing is a good
example of this as illustrated in the previous quote, implying a large difference
between ‘ordinary’ (or general) nurses and SNS. The previous section illustrated that
the Polish nurses were relatively powerless which can in part be attributed to their
lack of specialisation:
No we don’t have the stroke [specialist] nurses [...] the nurses here in Poland are
mostly involved in taking care and the washing and bed making with the patients.
(Neurologist, PCS)
This weak position of non-specialist nurses, was not restricted to Poland, it was also
echoed in very similar terms in our English case studies by all the professional
groups:
Again I think there’s a difference between the professions. The therapists are very
self motivated. […] it may well be that they [general nurses] spend so much time
wiping bottoms and cleaning up vomit and that sort of thing that actually they don’t
have the energy and that’s fine, because when push comes to shove nobody else
does that work and that’s their ultimate goal. And I mean they don’t seem to be
enormously motivated to actually bring themselves on to learn new things. (Stroke
consultant, ECS2)
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It is interesting in this following quote how the specialist nurse refers to general
nurses as ‘other’, and not a group that she belongs to:
I don’t think it’s their [general nurses] fault, because they’re not educated, because
the information is not always available to them, but I think nurses often struggle to
see the bigger picture. (SNS, ECS1)
This physiotherapist sums up the low status of non-specialist nurses:
I do have huge concerns about calibre of recruitment with nursing staff. I think they
see themselves as the, they see themselves and are treated as the troops really, as,
you know, the grunt workforce. (Senior Physiotherapist, ECS1)
Some informants attributed England’s non-specialised nurses’ lack of engagement
with their difficult position on the ward compared to therapists:
… when I look at the time that therapies have for supervision for in service, and I
know that the nurses don’t have that, and it isn’t part of their culture yet. And if it is,
it’s perhaps not very effective. And there’s so many of them, and you’ve got a shift
system (ECS1 Senior Physiotherapist)
However, one of the therapists questioned this perceived operational problem:
… we have 2.9 nurses per HASU [hyper-acute stroke unit] bed and 1.35 nurses per
stroke unit bed. Trust me, they have got time to come to a meeting. It’s not the
ethos, they just… they don’t get it and if they come to a meeting they sit resentfully
and don’t contribute, on the whole. (Physiotherapist, ECS2)
Conversely the prestige of SNS was clear in both England and Sweden:
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… our stroke nurses here are very competent. And they have a great position, I
think, among others, and that includes other doctors. (Departmental chief, SCS1)
… most of the leadership has come from elsewhere. And it’s come from a very
motivated stroke nurse specialist that we brought in from elsewhere and who had
been doing this before, who is, you know, just one of those people that knows their
subject, is passionate about their subject and communicates well. (Emergency
Consultant, ECS1)
It is only by combining the two aspects of EBP and specialisation that we can arrive
at a clearer view of the inter-professional authority in our five case study sites. The
concepts of EBP and specialisation are combined in table 2 below, which
summarises the results by charting the different professions’ degrees of
specialisation and EBP.
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Table 2: Inter-professional degrees of EBP and specialisation
Doctors Nurses Therapists
Poland High degrees of
specialisation
and EBP
Low degrees of
specialisation and EBP
Mixed degrees of
specialisation
and EBP
ECS1
High degrees of
specialisation
and EBP
Two groups:
SNS: high degree of
specialisation and mixed
degree of EBP
Non-specialised nurses:
low degrees of
specialisation and EBP
High degree of
specialisation
and mixed
degree of EBP
ECS2
Mixed degrees
of specialisation
and EBP
Two groups:
SNS: high degree of
specialisation and mixed
degree of EBP
Non-specialised nurses:
low degrees of
specialisation and EBP
Predominately
high degree of
specialisation
and mixed
degree of EBP
SCS1
Mixed degrees
of specialisation
and EBP
High degrees of
specialisation and EBP
Low degree of
specialisation
and mixed
degree of EBP
SCS2
High degrees of
specialisation
High degrees of
specialisation and EBP
Mixed degrees of
specialisation
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Discussion
The results illustrate how the two notions of evidence and specialisation are linked
and influence inter-professional competition. The results demonstrate that the
and EBP and EBP
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medical profession has not been able to simply claim full jurisdictional control of
stroke care; instead a more nuanced picture emerges.
Table 2 illustrates that doctors display a mixed to high degree of EBP and
specialisation across the five cases. In spite of this mixed picture they maintain a
high degree of professional jurisdiction over stroke care, winning the inter-
professional competition regardless of their degree of EBP and specialisation. The
fact that the clinical lead in all the sites was a doctor and audit data shows that this is
the case in 97% of SUs (RCP, 2014) is testament of this. Doctors derive this
jurisdictional power due to the fact that they originate from and continue their
affiliation to the dominant profession of medicine (Abbott, 1988) and maintain their
dominance through their high structural legitimacy in these formal institutional
structures (Lockett et al, 2012). Degrees of specialisation and EBP are more
important for the subordinate healthcare professions of nursing and the therapies.
Our results show that nurses are differentiated by country in terms of their degrees of
EBP and specialisation. In Sweden and England an elite group of nurses is able to
specialise and thereby gain a partial degree of jurisdiction of stroke care but the non-
specialised nurses in these countries have no jurisdictional power, indicating an
intra-professional difference. Similarly, Polish nurses who cannot specialise also lack
any jurisdiction of stroke care. SNS are a good example of a subordinate profession
(nursing) strengthening their jurisdiction by developing a specialised knowledge,
what Abbott termed the “the relevant level of abstraction” (p.111).
These advances have been aided in Sweden and England (but not Poland) by the
development of protocols that emphasise the key role of SNS; thrombolysis is a
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good example. Stroke specialist doctors hold on to their strong medical affiliation and
develop their specialty within medicine, while, SNS strengthen their jurisdictional
claims by differentiating and distancing themselves from their weaker non-specialist
nurse peers. In England and Sweden, stroke doctors collaborate with SNS who are
needed to deliver the specialist services such as thrombolysis in order to maintain
stroke’s distinct jurisdiction within hospitals. In this task evidence is crucial and the
strong evidence for acute stroke care gives power to specialist stroke professionals
(doctors and nurses) who are able to develop specialist knowledge and powerful
roles together. In contrast community therapists and non-specialist nurses can offer
little to this broader jurisdictional fight.
A less clear picture emerges for therapists; their jurisdiction tends to be largely
determined by their degree of specialisation irrespective of their degree of EBP,
although their general research focus helps. Therapists in England, and to a lesser
extent Poland, who are able to specialise on stroke patients have a relatively high
professional jurisdiction despite their mixed degree of EBP. In Sweden where
therapists are managed centrally, rather than by the SU, their ability to exclusively
treat stroke patients is restricted and so their jurisdiction of acute stroke care is
weaker, but have managed to retain their jurisdiction within the less important
rehabilitation services where doctors are largely absent and generally less
professionally interested. The therapists, who can claim to be stroke specialists in
England and Poland, continue to enjoy a high status in spite of their largely low
degree of EBP.
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Our results suggest that a profession’s jurisdictional strength is largely determined by
their degree of specialisation rather than their degree of EBP. Notwithstanding this
finding, the notion of evidence has been instrumental in enabling stroke care to
become a medical specialty and thus a distinct professional jurisdiction. Our data
would suggest that EBP has been an important factor in developing stroke into a
higher status specialist area but has been less important within the stroke world,
where a profession’s degree of specialisation and their ability to treat stroke patients
exclusively largely determines their status rather than their use or non-use of EBP.
However, the importance of evidence should not be ignored but needs to be better
understood, the coterminous rise of EBP and specialisation means that a non-
evidence based specialist professional could not now be countenanced in stroke
care. Our results suggest that continued medical dominance and EBP are both
mutually reinforcing in stroke medicine: EBP helps to perpetuate medical dominance
and medical dominance helps shape what EBP looks like (i.e. the primacy of the
RCT). In addition the EBP paradigm gives greater importance to acute (expensive)
medical treatment as opposed to (cheaper) community rehabilitation.
Finally we reflect upon the study’s limitations and areas for further research. In
Poland half of the interviews were in English and in the remainder AF used an
interpreter. Initially it was more difficult to develop a ‘responsive’ approach (Rubin &
Rubin, 2011) in the interpreted interviews, but it was the only way to hear the
opinions of the non-English speaking informants. In Sweden, informants were
offered an interpreter but no informants requested this and the standard of English in
all but one of the interviews was excellent. AF was careful to present the research in
neutral terms so as not to induce overly positive or negative responses about EBP
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from the informants. Longitudinal studies, including detailed observations of how
teams function would be valuable in future research. It would also be interesting to
conduct further international work to provide a richer comparative data set. Lastly,
other medical specialities could be studied (e.g. cardiology) to examine whether the
findings from this study are evident in different healthcare systems and settings.
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